Four patient blood management cases and explanations presented to medical students
| Case 1 | Description | A 60-year-old female patient visited the gastroenterology clinic with persistent melena for the past year. There were no other significant symptoms, and her vital signs were stable. The patient had received two RBC transfusions at a local hospital, and during the second transfusion, she experienced symptoms of respiratory distress, hypotension, and loss of consciousness. |
| CBC | WBC-Hb-Hct-PLT 5,000/μL - 8.0 g/dL - 24.1% - 250,000/μL | |
| MCV 78 fL, MCHC 28 g/dL | ||
| Chief complaint | -Melena persisted for a year | |
| -Vital signs were stable | ||
| Considerations: Anemia caused by small amounts of long-term gastrointestinal bleeding is not an indication for blood transfusion. If the general condition is good, a hemoglobin level of 7 g/dL or less is used as the standard for transfusion. Therefore, RBC transfusion was not indicated for this patient. | ||
| Underlying disease | NA | |
| Transfusion history | -Two RBC transfusions | |
| -Transfusion-associated symptoms, including dyspnea, hypotension, and loss of consciousness | ||
| Considerations: The intention was to diagnose an anaphylactoid reaction and select washed RBCs, but allergy-related symptoms were missed. As a result, AHTR, TRALI, and an anaphylactoid reaction had to be distinguished. | ||
| Laboratory test | -Microcytic hypochromic anemia | |
| -Hb 8.0 g/dL | ||
| Considerations: IDA evaluation and iron supply | ||
| Case 2 | Description | A 55-year-old male patient undergoing treatment for MDS presented to the hospital with epistaxis, which was successfully controlled. His vital signs were stable. The patient had received several blood transfusions to date, but he complained of being afraid of transfusions because he had a history of brown urine, low-grade fever, body aches, and headache three days after receiving an RBC transfusion at another hospital one year earlier. |
| CBC | WBC-Hb/Hct-PLT 3,000/μL - 7.0 g/dL - 21.4% - 250,000/μL | |
| MCV 108fL, MCHC 33 g/dL | ||
| Chief complaint | -Epistaxis successfully controlled | |
| -Vital signs were stable | ||
| Considerations: Although a Hb of 7.0 g/dL is a criterion for determining a blood transfusionin chronic anemia accompanied by blood diseases, ESA treatment should also be considered based on the MDS category. Blood transfusions should not be recommended for asymptomatic MDS patients without proper evaluation. | ||
| Underlying disease | -MDS | |
| Considerations: MDS is an indication of leuko-reduced and irradiated blood products. | ||
| Transfusion history | -Several RBC transfusions | |
| -Brown urine, low-grade fever, body aches, and headache three days after transfusion | ||
| Considerations: DHTR can be caused by unexpected antibodies and antigen-negative RBCs should be selected for transfusion to prevent this. | ||
| Case 2 | Laboratory test | -Macrocytic normochromic anemia |
| -Hb 7.0 g/dL | ||
| Considerations: ESA treatment may be considered to improve anemia in MDS patients. However, to ensure the effectiveness of ESA therapy, it is essential to identify the patient's MDS prognostic category, serum EPO levels, and transfusion dependence, as these factors can affect the patient's response to treatment. | ||
| Case 3 | Description | A 21-year-old female patient scheduled for tonsillectomy in three weeks underwent preoperative testing. The patient received an RBC transfusion when she was younger and experienced a mild fever afterward. She was advised to inform healthcare providers of this incident when hospitalized or undergoing surgery in the future. |
| CBC | WBC-Hb/Hct-PLT 5,000/μL - 8.0 g/dL - 24.1% - 250,000/μL | |
| MCV 78 fL, MCHC 28 g/dL | ||
| Chief complaint | -Scheduled tonsillectomy after three weeks | |
| -Vital signs were stable | ||
| Considerations: Asymptomatic chronic anemia requires finding the cause of the anemia and performing treatment according to a specific diagnosis. In this patient, although the hemoglobin level was reduced to 8.0 g/dL, it is important to prioritize anemia assessment over immediate transfusion. | ||
| Underlying disease | NA | |
| Transfusion history | -One RBC transfusion | |
| -Mild fever after transfusion | ||
| Considerations: Given that an FNHTR is suspected, it is advisable to select leuko-reduced blood to minimize the risk of transfusion-related complications. | ||
| Laboratory test | -Microcytic hypochromic anemia | |
| -Hb 8.0 g/dL | ||
| Considerations: IDA evaluation and iron supply | ||
| Case 4 | Description | A 45-year-old male patient with liver cirrhosis presented with esophageal varix bleeding and underwent an immediate variceal embolization procedure. The patient was scheduled to receive a liver transplant from his son in a week. There are no signs of current bleeding. Although the patient received multiple blood transfusions, he did not experience any significant symptoms. |
| CBC | WBC-Hb/Hct-PLT 7,000/μL - 6.0g/dL - 18.1% - 250,000/μL | |
| MCV 102 fL, MCHC 34 g/dL | ||
| Chief complaint | -Controlled esophageal varix bleeding | |
| Considerations: Since Hb levels were reduced to 6.0 g/dL due to acute blood loss,RBC transfusion should be considered. Furthermore, given that liver transplantation surgery is likely to result in significant bleeding, it may be necessary to delay the surgery or consider intraoperative blood salvage. | ||
| Case 4 | Underlying disease | -Liver cirrhosis |
| -Scheduled liver transplant after a week | ||
| Considerations: In organ transplant patients, leuko-reduced blood should be selected to prevent HLA immunization. Moreover, since patients receive immunosuppressive treatment, including anti-thymocyte globulin, after transplantation, irradiation should also be considered. | ||
| Transfusion history | -Several RBC transfusions without adverse events | |
| Laboratory test | -Macrocytic normochromic anemia | |
| -Hb 6.0 g/dL | ||
| Considerations: While RBC transfusion is necessary, it is necessary to check for MA and supplement any deficiencies in vitamin B12 and folic acid. |
Abbreviations: CBC, complete blood count; WBC, white blood cells; Hb, hemoglobin; Hct, hematocrit; PLT, platelets; MCV, mean copuscular volume; MCHC, mean corpuscular hemoglobin concentration; RBC, red blood cell; NA, not applicable; AHTR, acute hemolytic transfusion reaction; TRALI, transfusion-related acute lung injury; IDA, iron deficiency anemia; MDS, myelodysplastic neoplasm; ESA, erythrocyte stimulating agent; DHTR, delayed hemolytic transfusion reaction; EPO, erythropoietin; FNHTR, febrile non-hemolytic transfusion reaction; MA, megaloblastic anemia.